Acceptance and Commitment Therapy for Chronic Pain

JoAnne Dahl

Sujets

• Sociologie, société et politique
• Clinical psychology

Informations

• Publié par: New Harbinger Publications
• Date de parution: 01 janvier 0001
• Nombre de lectures: 0
• EAN13: 9781608826681
• Langue: English

Extrait

Dedication
To my favorite young women, Emma, my daughter, and Jenny, my niece, along with all of my female students. May this book serve as a source of inspiration for you as young women to have the courage to take a step forward in the light of your own unique vitality, show your greatness and by doing so make your special contribution towards bettering our world. (JD)
To my mom and dad, Barbara and Jim,
for their unending support and love (KGW)
To the students, who were willing to accept their own pain in order to help patients live a valued life with theirs (CL)
To Jacque, Happiness is Love (SCH)
JoAnne Dahl
Uppsala University
Kelly G. Wilson
University of Mississippi
Carmen Luciano
University of Almer a
Steven C. Hayes
University of Nevada, Reno
Context Press
Reno, NV -->
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Acceptance and Commitment Therapy for Chronic Pain
Paperback pp. 223
Distributed by New Harbinger Publications, Inc.
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epub ISBN: 9781608826681
Library of Congress has the print book cataloged as:
Acceptance and commitment therapy for chronic pain / JoAnne Dahl ... [et al.]. p. cm.
Includes bibliographical references.
ISBN-13: 978-1-878978-52-3 (pbk.)
ISBN-10: 1-878978-52-7 (pbk.)
1. Chronic pain—Treatment. 2. Behavior therapy. I. Dahl, JoAnne, 1951-
RB127.A24 2005
616'.0472—dc22
2005008039
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© 2005 Context Press, an imprint of New Harbinger Publications, Inc.
5674 Shattuck Ave, Oakland, CA 94609
All rights reserved.
No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher.
All drawings and cover by Jonathan Dahl.
Preface
The handbook you now have in your hands represents, for me, over 25 years of practical clinical and clinical research in rehabilitation medical centers trying to help clients who are “stuck” in chronic pain get “loose” and go on with their lives. The application of behavioral analysis on physical symptoms was a revolutionary development called behavior medicine that got started in the 1970’s. It was radical because it actually entailed a paradigm shift from a mechanical medical model to a whole new conceptualization of illness which included the learning model. The principles of conditioning were now being combined with medical know-how into a synthesis model of treatment that really made a difference in helping people with chronic illness regain function and life quality. The greatest difference produced by this marriage of behavior therapy and medicine was the concept of context. According to the medical model, physical illness occurred within the body and was caused by some pathological process. Consequently, the aim of treatment was to find that pathology and alleviate it. What behavior analysis brought to the marriage was the concept that no symptom takes place in a vacuum. All physical symptoms are amenable to the principles of learning.
The radical difference shown in this new paradigm was that the probability of developing a chronic disability was not determined by the actual symptoms themselves but rather the conditioning or context. Subsequently behavior therapists within the medical units would “diagnose” using functional analyses of the context of the symptom. This was done together with the whole rehab team. The two-step analysis was used to hypothesize the context of what the classical conditioning took place from the start and how the operant conditioning developed mostly in the form of fear-avoidance of the symptoms. Subsequently, treatment aimed at “de-conditioning” the symptoms by means of exposure on all fronts. This implied that each rehab team member would work within this functional analysis context and aim at de-conditioning by means of exposure. The context of this de-conditioning process was usually fairly pre-set. Insurance companies or employers paying for the rehabilitation wanted the client back to work. The rehab team members, often educated within the medical model, had pretty firm ideas as how to get the client back on his or her feet and back to work. Physical therapists aimed at helping clients strengthen and relax muscles, gain a better physical fitness and regain normal movement patterns. Occupational therapists aimed at helping clients work more ergonomically and expose themselves to work-like activities. Social workers aimed at helping the client get started in getting back to work. The CBT psychologist led the team in exposure and often worked in groups helping the clients to increase social skills and use different cognitive techniques for reducing negative thoughts. This type of CBT multi-disciplinary program for chronic pain truly represents a giant step in how we conceptualize and treat chronic illness. Today, such programs are seen as the treatment of choice for chronic pain.
The application of Acceptance and Commitment Therapy for chronic illness generally and specially for chronic pain is, to my mind, the next giant development. Again, it has to do with the development of the concept of context. About five years ago, I attended a workshop by Kelly Wilson here in Sweden on ACT. Kelly was putting his finger on something in the ACT model that struck me as sorely missing from the CBT model of chronic pain as I had worked with it and seen it, in many places. Kelly spoke about the concept of using the client’s values as the context of exposure and using the functional analysis even for the conceptualization and subsequent treatment of the client’s language. Kelly also demonstrated a very different therapeutic posture than the sort of teacher/student positioning that I was used to within CBT.
If you look at the empirical studies evaluating the CBT multi-disciplinary treatment of chronic pain, there is relatively good evidence as to its effectiveness with respect especially to helping clients back to work. Why then, should we go on to something else, if this is working so well? A good hard look at what goes on in these clinics will help you to see why the ACT model “hit home” on a number of issues. First of all, several major scientific reviews have shown that the CBT model is more helpful than traditional medical treatments alone in helping getting clients back to work, but due to the multiple components of treatment, none have been able to shed light as to what is working. Also there are very few randomized controlled trials with adequate control conditions. A particularly difficult problem, with almost all of the evaluation studies done on CBT multi-disciplinary programs, is that the rehab physicians on these same units are in charge of the most important dependent variable, the disability certificate. There is a contract from the start from the insurance agencies sponsoring the rehabilitation that at the end of the treatment period, the sick certificate will be terminated. The end result is in fact defined from the start and what happens during that period may not be of much consequence. This is a sure way to get results! This somewhat “hidden” agenda is the source of much conflict between the rehab staff and the clients.
Try and picture this scene. The client with chronic pain comes to the rehab clinic because pain and resulting disability has stopped him or her from working and functionally generally. Consider also the fact that most persons with pain in the neck, back or shoulders never seek help at all and of those who do, most recover quickly or find that they have a progressive illness that needs attention. Those persons, who do not have a progressive illness, do not get better from the usual treatment and who get “stuck” in chronic pain and disability are those who come to rehab. Most often these individuals have already been treated with suspicion questioning the authenticity of the disability due to the fact that they have not improved as expected. They will also be aware of the social frowning on those who are seen as “cheating” the health insurance systems by simulating pain symptoms for the economic gains of disability payments. In our culture, any kind of pain that is not physical and associated with some organic pathology is under suspicion of not being “real”. So, picture this individual, overwhelmed with pain symptoms, whose credibility is questioned by the health care system, employer, friends, and family, now being coerced into complying with a rehabilitation program.
The rehab team, on the other hand has about an 8-week period to fulfill their contract and get the person back to work. By means of the functional analysis the team creates a hypothesis regarding what types of activities, movements or situations that have been conditioned to pain. The treatment plan aims at de-conditioning these associations by means of exposure. The major problem facing the rehab staff is that the client is not on this wavelength and just the thought of exposure is aversive for this individual. Besides the fact that we are asking them to do things they are convinced will increase their already unbearable pain, we are also in a sense saying that they are wrong in their thinking. We are in essence saying that their pain is not “real”, it is psychological. As if that weren’t enough to set the stage for a poor therapeutic alliance, the insurance companies are standing behind the staff so that any non-compliance can result in loss of disability payment. You can imagine what types of behavior patterns these contingencies form. At worse, there is an atmosphere of “we” and “them” between the staff and the clients fighting for diametrically different goals. There is often conflict between the players, resulting in “burn out” among the staff and “pliance” or rule